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H P Müller

Publications and source records attributed to H P Müller.

At least 19 recordsLinked to original sources

Effect of triclosan/copolymer-containing toothpaste on the association between plaque and gingival bleeding: a randomized controlled clinical trial.

AIM: To study longitudinal associations between plaque and gingival bleeding and multilevel variance/covariance structures after introducing triclosan-containing toothpaste. MATERIAL AND METHODS: A 10-week, randomized, two-arm, double-masked, controlled clinical trial was conducted in 34 healthy, non-smoking females with plaque-induced gingivitis. Clinical periodontal examinations were repeated every other week. At week 4, test toothpaste containing 0.24% sodium monofluorophosphate, 0.3% triclosan, and 2% polyvinyl-methyl ether maleic acid; or control toothpaste containing 0.76% sodium monofluorophosphate and 0.1% sodium fluoride, were randomly distributed. RESULTS: Multivariate multilevel models indicated that, after introducing experimental toothpastes, subject random error was reduced from 0.6 to below 0.2. The odds ratio (OR) of bleeding on probing (BOP) was about 30% less in the test than in the control group (p<0.01). At the end of the experiment, ORs for BOP and plaque index scores 1-3 (reference 0) were 2.1-2.4 in the control group, but 1.1-1.9 in the test group (p<0.05). No effects on plaque levels and calculus were observed. CONCLUSIONS: Multivariate multilevel modelling allows the study of fixed and random effects of experimental toothpastes on gingival inflammation in small sample. Triclosan appears to attenuate the causal association between supragingival plaque and gingival bleeding in gingivitis.

Adult↗

Multivariate multilevel models for repeated measures in the study of smoking effects on the association between plaque and gingival bleeding.

Multivariate multilevel modeling was applied to analyze repeated measures data on the influence of heavy smoking on the association between the amount of supragingival plaque and gingival bleeding on probing (BOP) in a steady-state plaque environment. Data acquired in 65 systemically healthy young adults with mild plaque-induced gingivitis were analyzed. 33 heavy smokers consumed at least 20 cigarettes per day while 32 were non-smokers. Periodontal examinations at the outset consisted of periodontal probing depth, clinical attachment level, BOP, plaque index, and presence of calculus at 6 sites of every tooth present. They were repeated 3 times every 8 weeks. A multivariate 4-level variance component model revealed that the odds of BOP was twice as high in smokers. In addition, females had a lower likelihood for BOP but, with increasing bleeding scores during the course of the study, this effect attenuated. Low biserial correlations for BOP at the site level of between 0.11 and 0.2 were found. At the tooth level, correlations were moderate (0.2-0.5), and highest at the subject level (0.8-0.9). Variations at subject and tooth levels were very large at the outset but notably attenuated in the course of the study. Plaque consistently influenced the tendency for BOP with an odds ratio of about 1.7-1.8 for each increase in score in both smokers and non-smokers. The present study did not reveal evidence for attenuation of the plaque/gingival bleeding relationship in heavy smokers.

Adult↗

Gingival bleeding on repeat probing after different time intervals in plaque-induced gingivitis.

The aim of this study was to assess agreement and association of gingival bleeding after repeated probing at different time intervals in subjects with gingivitis. Twenty adults participated. Periodontal probing (P approximately 1.27 MPa) was conducted at six sites of every tooth present. Probing was repeated in different quadrants immediately after the first probing (T0), after 1 h (T1), 4 h (T4), and 24 h (T24). A total of 3,459 sites were probed twice. The mean proportion of sites bleeding on probing (BOP) was 0.23 (standard deviation 0.08, range 0.10-0.41). Probing itself had a significant effect on the results of repeated probing. For T0 through T24, respective mean differences of proportions were 0.04, 0.04, 0.01, and -0.03. Ninety-five percent repeatability coefficients of proportions were 0.17-0.18. Estimates of overall kappa were 0.390, 0.234, 0.233, and 0.046 for T0 through T4, respectively. Adjusted two-level binary response models revealed odds ratios (95% confidence interval) for BOP at T0 through T4 of 6.52 (4.34, 9.80), 3.23 (2.19, 4.76), 3.80 (2.63, 5.50), and 2.68 (1.85, 3.89). It was concluded that a certain degree of agreement of site-specific bleeding scores in subjects with plaque-induced gingivitis could be observed only if probing was repeated at once. Adjusted associations between repeat BOP were weak in general, but strongest immediately after first probing. There appears to be a significant effect of probing itself, which may last for more than 1 h, whereas 24-h results are obtained under different conditions.

Adult↗

Variance components of gingival thickness.

OBJECTIVES: Distinct periodontal phenotypes have been identified by cluster analysis, which is an explorative method with very low external validity. The aim of the present study was to investigate variance components of facial gingival thickness in young adults with mild gingivitis. MATERIAL AND METHODS: Thirty-three non-smoking females, 18-23 years of age, with mild or moderate plaque-induced gingivitis participated. Gingival thickness was measured at every tooth present by use of ultrasound technology to the next 0.1 mm with a lowest measurement of 0.5 mm. Periodontal probing depth and clinical attachment level were measured with a pressure-controlled probe. Gingival bleeding index was assessed after probing on a 0-2 scale, where 1 was slight, and 2 was profuse bleeding on probing. The Silness-Loe plaque index was recorded. Multilevel variance components and random intercept models were built. RESULTS: A 2-level (subject, tooth) variance component model of gingival thickness without any explanatory variable revealed an intercept (mean) of 0.93 +/- 0.02 mm. Subject variation of gingival thickness amounted to 4.2% of the total variance. Addition of tooth- and subject-related covariates to the model revealed, after adjusting for tooth type, an association with periodontal probing depth (estimated coefficient 0.067 +/- 0.025), and considerable association with average bleeding index (-0.395 +/- 0.149) and plaque index (0.125 +/- 0.048). Variation at the tooth level was drastically reduced; subject variation amounted to 5.2%. CONCLUSION: Gingival thickness is mainly associated with tooth-related variables. Bleeding tendency is higher if gingiva is thin. Subject variability related to periodontal phenotype may add to the total variance, however, to a very low extent.

Adolescent↗

The influence of gingival dimensions on bleeding upon probing in young adults with plaque-induced gingivitis.

In both cross-sectional and longitudinal studies of young adults with plaque-induced gingivitis it has been observed that bleeding upon probing is only weakly associated with supragingival plaque. It has been speculated that gingival bleeding may be influenced by several independent factors other than plaque. Great intra- and interindividual variation of gingival thickness and width has been reported. Based on respective observations, the existence of different gingival phenotypes has been suggested. The aim of the present study was to investigate the possible influence of gingival thickness and width on bleeding on probing. Forty young adults with mild, plaque-induced gingivitis, 24 non-smokers and 16 smokers, participated in this cross-sectional study. In addition to periodontal probing depth, clinical attachment loss, width of gingiva, bleeding on probing, and presence of plaque, gingival thickness was measured with an ultrasonic device. Multivariable models were separately calculated for buccal, mandibular lingual, and palatal surfaces and generally adjusted for tooth type. Generalised Estimation Equation methodology was employed in order to adjust for correlated observations. Plaque was significantly associated with bleeding upon probing only at buccal sites (odds ratio 1.80, 95% confidence interval 1.19-2.72) An influence of similar magnitude was identified for smoking (odds ratio 1.76; 1.07-2.89). At lingual sites in the mandible, bleeding was influenced by smoking (odds ratio 2.25; 1.18-4.25) and gingival thickness (odds ratio for thick gingiva >1 mm of 1.93; 1.02-3.65), but not plaque. At palatal sites, only periodontal probing depth had an influence (odds ratio 1.89; 1.25-2.84). It was concluded that, apart from supragingival plaque, smoking was an independent risk factor for gingival bleeding on probing. Thin and vulnerable gingiva of insufficient width was not more likely to bleed after probing than thicker tissue.

Adult↗

[Does chronic periodontitis play a role in the pathogenesis of cardiovascular and cerebrovascular diseases?].

The role of chronic infections in the initiation of atherosclerotic lesions has been vividly discussed in recent years. A possible causal relationship between cardiovascular diseases and infections with, e. g., Chlamydia pneumoniae, Helicobacter pylori, or herpes viruses had also been established for chronic periodontitis, in particular after discovery of DNA of typical periodontal pathogens in atheromatous plaques. Especially in longitudinal epidemiologic studies, a low or moderate association between existing periodontitis and the development of, e. g., coronary heart disease or non-haemorrhagic stroke had been observed. In this article the respective literature is critically reviewed. In particular, the influence of incomplete or inappropriate adjustment for common risk factors for both diseases, i. e., cardiovascular disease and periodontitis should be analysed. In metaanalyses of prospective studies, in which the respective endpoint occurred after the investigation had commenced, relative risks of periodontitis of 1.12 (95 % confidence interval 0.95-1.33) for coronary heart disease and 1.73 (0.89-3.34) for ischaemic stroke were calculated. Whether chronic periodontitis actually represents an important risk for the development of cardiovascular diseases remains questionable. Already planned intervention studies appear to be premature and ethically highly problematic.

Cerebral Infarction↗

[Quality management: internal guidelines and critical pathways for patients].

BACKGROUND: The construction and implementation of "Practice Guidelines" was one of the most important developments in American medicine of the last 15 years. There is ongoing controversy about the effectiveness of these guidelines to get introduced into practice. It has been proved, however, that guidelines developed by care organizations themselves, will show a higher effectiveness and acceptance and will achieve more positive results (Internal Guidelines, "Locally Owned" Standards). "Mipp": Internal Guidelines are also the starting point for the patient pathways of the model of integrated patient pathways "mipp", developed at the Kantonsspital Aarau in the last 7 years. The model is presented with its main features: Construction and Implementation of Pathways, Path-Controlling, Path-Benchmarking and Path-Visualization. "Mipp" Pathways share with Clinical Pathways the interdisciplinary perspectives for an efficient quality management. The description of processes is combined with an integrated calculation of costs, which is the basis of standard cost accounting and even activity based-costing. CONCLUSION: In the field of upcoming prospective payment systems (PPS) like ARDRG, APDRG etc. it is of utmost importance for care organizations to have a clear view regarding the treatment processes and the possibilities of their improvement.

Benchmarking↗

Magnetocardiographic mapping of QRS fragmentation in patients with a history of malignant tachyarrhythmias.

BACKGROUND: The identification of patients at increased risk for ventricular tachycardia or ventricular fibrillation (VT/VF) and sudden cardiac death has consequences for therapeutic options and thus may reduce mortality in patients with coronary artery disease (CAD). HYPOTHESIS: We hypothesized that the intra-QRS fragmentation in magnetocardiographic recordings is increased in patients with CAD and with a history of VT/VF. METHODS: Multichannel magnetocardiography (MCG) was carried out in 34 healthy controls, 42 patients with CAD without a history of VT/VF, and 43 patients with CAD and with a history of VT/VF. The intra-QRS fragmentation was quantified by a new fragmentation score. Its spatial distribution was investigated using two-dimensional (2-D) contour maps according to the sensor position of the 49-channel magnetogradiometer. RESULTS: Patients with CAD and with a history of VT/VF had significantly increased QRS fragmentation compared with patients with CAD without VT/VF or controls (72.9+/-37.5, 48.5+/-14.3, and 42.5+/-7.8, respectively: p <0.05). The area of high fragmentation in 2-D contour maps was twice as large in patients with than in those without a history of VT/VF (represented by the number of MCG channels with high fragmentation: 26.3+/-15.5 vs. 12.4+/-9.9, p<0.0001). Patients prone to VT/VF could be identified with a sensitivity of 64% and a specificity of 90%. CONCLUSION: In patients with CAD and with a history of VT/VF, intra-QRS fragmentation is increased and the area of high fragmentation in 2-D contour maps is enlarged. These findings may be helpful in identifying patients with CAD at risk for malignant tachyarrhythmias.

Adult↗

Gingivitis in young adults with Actinobacillus actinomycetemcomitans.

High intraoral load of A. actinomycetemcomitans in subjects with no or minimal periodontal disease may induce subtle changes in clinical periodontal conditions. The aim of the present study was to compare, at a site level, clinical conditions in two groups of young adults with plaque-induced gingivitis. In one group, more than 20% subgingival sites harboured cultivable A. actinomycetemcomitans (n=9), whereas in the other group, the organism was present in 20% or fewer subgingival plaque samples (n=8). Whereas no overt differences in clinical conditions could be ascertained, on average, the association between the presence of subgingival plaque and bleeding upon probing was considerably stronger (Mantel-Haenszel's common odds ratio RMH and 95% confidence interval 3.903, 2.951-5.165, P<0.001) in subjects with only a few subgingival sites harbouring A. actinomycetemcomitans as compared to subjects with a widespread intraoral distribution of the organism (R(MH)=1.637, 1.226-2.184, P<0.001). Since the proportion of sites not bleeding upon probing in the presence of supragingival plaque was slightly elevated in these subjects, the present findings may suggest a suppressed inflammatory reaction on supragingival plaque in the presence of a pronounced intraoral load of A. actinomycetemcomitans.

Adolescent↗

Bleeding on probing in smokers and non-smokers in a steady state plaque environment.

An altered gingival inflammatory response to supragingival plaque in smokers had been claimed by several authors. Relatively limited information exists with regard to the consistency of naturally occurring plaque and bleeding upon probing within the oral cavity under usual oral hygiene measures. The aims of the present study were to describe the distribution of tooth surfaces covered by supragingival plaque and gingival units bleeding upon probing in a steady state environment of no dental intervention. In addition relative consistency of plaque and bleeding was investigated. 65 volunteers, 14 women and 51 men in the age range of 19 to 30 years, participated. 33 volunteers were heavy smokers and 32 non-smokers. Clinical examinations revealed mild, plaque-induced gingivitis with no overt destructive periodontitis. Within a 6-month period. presence and amount of plaque, calculus and gingival bleeding was site-specifically assessed four times, i.e., every 8 weeks. Well-defined, symmetric and consistent patterns of plaque and calculus distribution within the oral cavity were observed, which were rather identical in smokers and non-smokers. Smokers had evenly more plaque in all regions of the oral cavity. In contrast, there was no obvious pattern of bleeding upon probing. Consistency of observations was considerably lower than for plaque scores. This was particularly true for smokers, where the association between bleeding scores was generally smaller than in non-smokers. A large portion of the variation of gingival bleeding may be due to presently unknown factors other than plaque and calculus with considerable consequences for preventive programmes.

Adult↗

Intraoral distribution of Actinobacillus actinomycetemcomitans in young adults with minimal periodontal disease.

The aim of the present study was to investigate the intraoral distribution of Actinobacillus actinomycetemcomitans in young adults with minor signs of periodontal disease but harboring the organisms in the oral cavity. 17 healthy volunteers, 20 to 27 years of age, participated. Samples from mucosal surfaces of the oro-pharyngeal cavity and saliva (n = 221) as well as subgingival plaque from every tooth (n =477) were selectively cultivated for A. actinomycetemcomitans. Species identity and presence of the leukotoxin encoding gene, ltxA, were checked by multiplex polymerase chain reaction. Moreover, the leukotoxin promoter region was analyzed. No isolate harbored a 530 bp deletion in the promoter region of the leukotoxin gene, signaling minimally toxic strains. 42.1 +/- 30.4% extracrevicular and 34.4 +/- 29.5% subgingival samples were culture-positive. In extracrevicular samples, the organism could easily be recovered from cheek mucosa (62%), saliva (59%) and the palatal tonsils (41%). Mean log-transformed numbers of A. actinomycetecomitans colony forming units (CFU/ml) in culture-positive material ranged between 1.8 from the hard palate and 2.3 from 10 microl saliva. The highest prevalence in subgingival plaque was observed at maxillary 3rd molars (55%) followed by maxillary lateral incisors (50%) and mandibular 3rd molars (41%). Mean log-transformed counts of CFU/ml ranged between 2.2 at maxillary 3rd molars and 3.4 at upper central incisors. When adjusted for jaw, site and tooth type, the odds of isolating higher numbers of the organism were increased with every mm probing depth by a factor of 1.35 (p <0.05). The odds ratio for bleeding on probing was 1.38. Thus, in this young adult population with minor periodontal disease, A. actinomyetemcomitans was mainly associated with some deviation from gingival health. Of concern might be a minority of subjects (29%) with an extremely wide distribution of the organism in the oral cavity.

Adolescent↗

ApoE-containing high density lipoproteins and phospholipid transfer protein activity increase in patients with a systemic inflammatory response.

High density lipoproteins (HDL) mediate reverse cholesterol transport as well as the clearance of oxidation products or inflammatory mediators, thereby contributing to tissue integrity. The decrease in HDL in inflammation has been attributed to decreased lecithin:cholesterol acyltransferase activity, whereas the role of phospholipid transfer protein (PLTP) and cholesteryl ester transfer protein has not been analyzed in detail. We have studied the activities of HDL-modifying proteins and the heterogeneity of HDL in healthy control subjects and three groups of postsurgery patients: no bacterial infection (group 1), bacterial focus and systemic inflammatory response (group 2), and severe sepsis (group 3). For all patients, a decrease in total HDL could be demonstrated, with a loss of mainly large, apolipoprotein A-I (apoA-I) HDL particles, an almost total loss of apoC-I, and an increase in apoE HDL (200-500 kDa), which did not contain significant amounts of apoA-I, apoA-II, or apoC-I. PLTP activity was increased in patients of groups 2 and 3, paralleled by a redistribution of PLTP into a population of small (120- to 200-kDa) particles, probably representing PLTP homodimers or lipid-complexed PLTP. In summary, the increase in apoE HDL and PLTP activity may improve the delivery of energy substrates and phospholipids to tissues that must maintain cellular membrane homeostasis under conditions of inflammatory stress.

Adult↗

Failure of root coverage of shallow gingival recessions employing GTR and a bioresorbable membrane.

The aim of the present study was to compare the postsurgical outcome of two different modes of surgical root coverage of predominantly shallow, Class I or II, gingival recessions. Fourteen facial recessions in nine patients were subjected to a coronally repositioned flap in combination with a bioresorbable membrane, and 14 sites in 13 patients were treated with a connective tissue graft employing an envelope technique. Immediately before surgery and after 6 and 12 months, gingival dimensions as well as root coverage and attachment gain were assessed. At baseline, mean recession depths amounted to 2.77+/-1.67 mm and 2.49+/-1.07 mm for patients treated with a bioresorbable membrane and a free connective tissue graft, respectively. Acceptable and stable root coverage of 81% to 82% of baseline recession depth and 78% of its width was achieved by grafting. In contrast, guided tissue regeneration (GTR) resulted in only 50% coverage of recession depth and, after 12 months, only 11% of its width (P < 0.01). Logistic regression revealed that the odds of obtaining success, ie, at least 80% root coverage, were 3.3 times greater in cases treated with a connective tissue graft (P < 0.05). In addition, the odds ratio was 2.3 in cases of recessions below 2.5 mm compared to deeper recessions and 2 at canines compared to premolars. It was concluded that shallow recessions in the 1.5 to 3.5 mm range should not be treated with GTR. In these situations, predictable results are achieved with free connective tissue grafts employing an envelope technique.

Absorbable Implants↗

Site-specific association between supragingival plaque and bleeding upon probing in young adults.

The aim of the present study was to consider supragingival plaque as a risk factor for gingivitis in a group of young adults without destructive periodontal disease. A total of 127 subjects, 17 to 30 years of age, participated. Periodontal probing depth, clinical attachment level as well as bleeding upon probing and supragingival plaque was assessed at 6 sites of every tooth present. The individual odds ratios between plaque and bleeding ranged between 0.237 and 66.6. 23% volunteers had an odds ratio of below 1.2. Only 15% individuals presented with an attributable risk of supragingival plaque for bleeding upon probing of 50% or more. Overall, the odds of bleeding, adjusted for periodontal probing depth, was increased by 67% in the presence of plaque. Large differences were observed at different teeth with the highest odds ratio at mandibular premolars with 2.557 (95% confidence interval 2.033-3.216) and the lowest at maxillary molars with 1.355 (1.161-1.732). It was concluded that there was high interindividual and intraindividual variation of the relative risk for bleeding in the presence of plaque. The observed low overall relative risk has important consequences in educational and health care programmes since the risk of supragingival plaque which is actually attributable for the observed bleeding on probing may be rather small.

Adolescent↗

Dynamics of mucosal dimensions after root coverage with a bioresorbable membrane.

BACKGROUND: So far, the clinical effects of the placement of a resorbable membrane for guided tissue regeneration have not been studied in humans in great detail. The dynamics of the resorptive processes, in particular, appear to be rather speculative. In the present longitudinal study, specific alterations of the dimensions of the dentogingival mucosa were explored after surgical root coverage by using a bioresorbable membrane and a coronally-repositioned flap. METHODS: The study population consisted of 14 patients with a total of 31 predominantly shallow, Miller class I, II or III recessions. The thickness of the masticatory and lining mucosa before and after surgical intervention was measured with an ultrasonic device. RESULTS: Mean (+/-sd) recession depth and width were 2.85+/-1.29 and 4.46+/-1.14 mm, respectively. After 12 months, 51+/-29% of the recession depth (p<0.001) and 13+/-35% of its width (n.s.) were covered. Root coverage seems to be rather defect-type sensitive with best results obtained at canines with relatively shallow recessions. Mucosal thickness was considerably increased after surgery with a gradual decrease during the following 9 months. Thus, thickness of the marginal tissue rose from 0.82+/-0.27 mm to 1.49+/-0.54 mm 3 months after placement of the membrane (p<0.001). After 12 months, a mean thickness of 1.03+/-0.40 mm was observed (p<0.001). Even more pronounced alterations were noted for the alveolar lining mucosa with a threefold increase of thickness 3 months after surgery and a gradual decrease to about 1 mm after 12 months. CONCLUSIONS: The present results point to the considerable space making capacity of the bioresorbable membrane which probably allows for the ingrowth of a granulation tissue derived from the underlying structures. The gradual decline in mucosal thickness between months 6 and 9 after surgery may be paralleled by the maturation of the granulation tissue while complete resorption of the membrane had been accomplished.

Absorbable Implants↗

Thickness of masticatory mucosa.

BACKGROUND: The aim of the present study was to assess thickness of all parts of the masticatory mucosa by using an ultrasonic measuring device. METHODS: A total of 40 periodontally healthy subjects, 19 to 30 years old, took part. Thickness of masticatory mucosa was measured at a maximum of 149 sites in each proband. RESULTS: Female volunteers had significantly thinner mean masticatory mucosa than males (p<0.01). Mean thickness of facial gingiva ranged between 0.7 mm at canines in the maxilla and central incisors in the mandible and 2.3 mm at 3rd molars in the mandible. In the mandible, thickness of lingual gingiva ranged between 0.9 mm at lateral incisors and 2.3 mm at 3rd molars. Interdental gingiva ranged between 1.0 mm 2.1 mm. With 3 mm or more, on average, palatal masticatory mucosa was thickest in the 3rd molar region and at 2nd premolars at more central locations. 2 regions with comparatively thin palatal mucosa of about 2 mm were identified, namely (i) at central and lateral incisors and (ii) at the prominence of the palatal roots of 1st and 2nd molars. The thickest tissue with more than 4 mm, on average, was observed in the tuberosity and retromolar regions. CONCLUSIONS: Considerable intra- as well as interindividual variation of thickness of masticatory mucosa could be observed. According to differences in thickness of facial and interdental gingiva, it appears that lining is also an important function of the gingiva in reducing and smoothing the pronounced convexities of the dentoalveolar, i.e., skeletal, complex.

Adult↗

Masticatory mucosa in subjects with different periodontal phenotypes.

AIMS: The aim of the present investigation was to study thickness of masticatory mucosa and gingival width in subjects with different periodontal phenotypes. METHODS: Periodontal phenotypes were defined with the aid of cluster analysis of standardised parameters including mean gingival thickness and width as well as ratio of crown width to its length at maxillary canines, lateral and central incisors of 40 young adults with healthy periodontal conditions. RESULTS: 3 groupings could be observed. Clusters A1 and A2 comprised 75% of all subjects. They were characterised by thin gingiva and a slender tooth form. Clusters A1 and A2 were differentiated by gingival width. Cluster B comprised 11 subjects with relatively thick and wide gingiva and a quadratic tooth shape. In general, characteristics of the frontal sextant in the maxilla were also found in other parts of the dentition. Thus, mean thickness of masticatory mucosa as well as gingival width and crown form differed significantly among clusters. In addition, cluster B subjects had a significantly greater mean periodontal probing depth. Multiple linear regression analysis was employed to identify significant factors influencing palatal mucosal thickness. Women had considerably thinner palatal mucosa than men. Furthermore, cluster affiliation had a significant influence on thickness of palatal mucosa. Thickest tissue was found in the premolar region, whereas the mucosa over the root prominence of the first molar represented an anatomical barrier for graft harvesting. CONCLUSIONS: Thickness of masticatory mucosa strongly depends on gender and the periodontal phenotype.

Adult↗